Opthalmology Flashcards
(459 cards)
1
Q
Site & Size of the macula
A
- The macula is a round area at the posterior pole, lying inside the temporal vascular arcades
- It measures between 5 and 6 mm in diameter and subserves the central
15–20° of the visual field
2
Q
Site & Size of the fovea
A
The fovea is a depression in the retinal surface at the centre of the macula, with a diameter of 1.5 mm – about the same size as of the optic disc
3
Q
What’s foveola
A
The foveola forms the central floor of the fovea and has a diameter of 0.35 mm
It is thinnest part of the retina and is devoid of ganglion cells, consisting only of a high density of cone photoreceptors and their nuclei, together with Müller cells
4
Q
Layers of the fovea (retina)
A
1- Nerve fibre layer
2- Ganglion cell layer
3- Inner plexiform plexus
4- Inner nuclear layer
5- Outer plexiform plexus
6- Outer nuclear layer
7- Layer of rods and cons
8- Retinal pigmented epithelium
9- Choroidal capillaries
5
Q
Compare between rods and cons
A
Rods (120m) ~> In the periphery - Responsible for night vision + black and white
~~> If damaged = Poor night vision (nyctalopia) + Peripheral visual field loss
Cones (6m) ~> In the centre - Responsible for day vision + Colours
~~> If damaged = Poor day vision (hemeralopia) + Colour blindness (dyschromatopsia)
6
Q
Blood supply of the retina
A
Outer 2/3:
ICA ~> Ophthalmic ~> Central retinal artery
Inner 1/3:
Choroid
7
Q
Retinal blood barrier
A
Inner blood retinal barrier ~> Endothelial cells + Pericytes
Outer blood retinal barrier ~> Retinal pigmented epithelium
8
Q
The diameter of retinal veins enlarge as they pass
A
Posteriorly
9
Q
OCT indications
A
- Diabetic retinopathy
- Retinal vein occlusion
- Age related macular degeneration
10
Q
What’s A scan and B scan
A
A scan ~> Measures axial length of the lens in biometry
B Scan ~> used to see the retina in cases of vitreous haemorrhage or retinal detachment so we can’t assess the retina by direct or indirect ophthalmoscope
11
Q
Retinal investigations
A
• Optical coherence tomography (OCT)
• Fundus fluorescein angiography (FA)
• B SCAN
• Electroretinography
• Genetic testing
12
Q
What’s unstable refraction
A
مريض السكري يشكوا من انعدام الرؤية اذا صعد سكره بسبب التأثير على العدسة (refractive power) ف تزداد قوة الانكسار مما يسبب pseudomyopia و blurring of vision ومن يرجع سكره طبيعي ترجع درجة او قوة الانكسار لطبيعتها وبالتالي يرجع النظر طبيعي وهذا هو معنى unstable refraction
13
Q
What’s pseudomyopia
A
مريض السكري يشكوا من انعدام الرؤية اذا صعد سكره بسبب التأثير على العدسة (refractive power) ف تزداد قوة الانكسار مما يسبب pseudomyopia و blurring of vision ومن يرجع سكره طبيعي ترجع درجة او قوة الانكسار لطبيعتها وبالتالي يرجع النظر طبيعي وهذا هو معنى unstable refraction
14
Q
DM + العين داخلة لجوا
A
6th nerve palsy
15
Q
DM + Complete ptosis
A
3rd nerve palsy
16
Q
DM + Corneal scar
A
Reduced corneal sensitivity
17
Q
The reported prevalence of diabetic retinopathy (DR) is probably around …
It is more common in type 1 diabetes than in type 2 and sight-threatening disease is present in up to …
A
40% —— 10%
18
Q
Relation between duration of diabetes and retinopathy
A
In patients diagnosed with diabetes before the age of 30 years, the incidence of DR after 10 years is 50% and after 30 years 90%
DR rarely develops within 5 years of the onset of diabetes or before puberty, but about 5% of type 2 diabetics have DR at presentation
19
Q
Screening for DR
A
Type 1 ~> After 5yrs then once every year
Type 2 ~> At time of diagnosis then once every year
20
Q
By decreasing the HbA1C by … the microvascular complications reduced by …
A
1% ——— 1/3
21
Q
Risk factors for rapid progression of DR
A
Sudden tight control of blood glucose level
Pregnancy
22
Q
Approximately … with mild DR and a … of those with moderate DR will progress to PDR during the pregnancy
A
5% ——— 1/3
23
Q
Factors in pregnancy make DR worse
A
Greater pre-pregnancy severity of retinopathy
Poor pre-pregnancy control of diabetes
Control exerted too rapidly during the early stages of pregnancy
Pre-eclampsia
24
Q
HTN control beneficial in type … diabetes to reduce DR progression
Diabetes control beneficial in type … to reduce DR progression
A
Type 2
Type 1
25
DR pathophysiology
DR is predominantly a microangiopathy in which small blood vessels
are particularly vulnerable to damage from high glucose levels
Direct hyperglycaemic effects on retinal cells are also likely to play a role
Many angiogenic stimulators and inhibitors have been identified (VEGF)
26
Signs of DR
• Microaneurysms (dot haemorrhages)
• Retinal haemorrhages
• Exudates (lipid deposits indicating chronic ischemia)
• Cotton-wool spots (neuronal debris)
• Venous changes
- Tortuosity, looping, beading, dilatation and sausagesegmentation
• Arterial changes
- peripheral narrowing, ‘silver wiring’ and obliteration
27
How cotton wall spots appear and where
Small fluffy whitish superficial lesions that obscure underlying blood vessels
They are clinically evident only in the post-equatorial retina, where the nerve fibre layer is of sufficient thickness to render them visible
28
The main subtype of non proliferative diabetic retinopathy which causes complications and needs intervention is
DMO
29
The most common cause of visual impairment in diabetic patients, particularly type 2
DMO
30
How DMO appear on OCT and FA
OCT ~> central accumulation of fluid, the fovea assumes a cystoid appearance cystoid macular oedema (CMO)
FA ~> assumes a central flower petal pattern
31
What’s normal thickness of retina and how it changes in DMO
Below 300 —— It may reach 500-700
32
In diabetic patients what causes visual loss occurs
Sudden vision loss ~> Vitreous haemorrhage due to proliferative DR
Progressive vision loss ~> Diabetic macular oedema (non proliferative)
33
Sites of neovascularisation in PDR
• New vessels at the disc (NVD) describes neovascularisation on or within one disc diameter of the optic nerve head
• NVE describes neovascularization further away from the disc
• New vessels on the iris (NVI), also known as rubeosis iridis, carry a high likelihood of progression to neovascular glaucom
34
What’s rubeosis iridis
New vessels on the iris (NVI) in patients with PDR
Carry a high likelihood of progression to neovascular glaucom
35
Rx of DMO
• Intravitreal anti-VEGF agents, aflibercept, bevacizumab or ranibizumab
• Laser photocoagulation
• Intravitreal triamcinolone (in resistant cases)
• Pars plana vitrectomy (PPV)
36
Strong predictor of long-term response to injections in a patients with DMO
Improvement in best corrected visual acuity after three injections of anti-VEGF
37
Do Fenofibrate have a role in Rx of DMO
Fenofibrate 200 mg daily has been shown to reduce the progression of DR in type 2 diabetics and prescription should be considered even if the patient is taking statin
38
The mainstay of PDR treatment in most healthcare systems
Scatter laser treatment (panretinal photocoagulation) = PRP
39
Severe neovascularization without haemorrhage carries a … risk of visual loss at 2 years that is reduced to … with PRP
26% ——— 9%
40
What’s more effective PRP or Anti-VEGF
Course of injections of intravitreal ANTI VEGF is as effective as photocoagulation in patients at high risk of PDR at 5 years
41
It is the second most common retinal vascular disease after DR
Central retinal vein occlusion
42
Anti VEGF course for patients with DMO
5 injections then maintenance every month or 3 or maybe lifelong
43
Can we give VEGF for patients with recent MI or stroke
No, wait for 6 months
44
Can neovascularisation occurs in central retinal veins occlusion
نعم ممكن لإن الي دا يصير هنا هو ischemia يعني يطلع VEGF بالتالي ممكن يصير لذلك بالعلاج ننطي 6 ابر مو 5 ويظل على follow up يوصل للسنتين او 3
45
Symptoms of retinal veins occlusion
A sudden painless monocular fall in vision
46
Signs of retinal vein occlusion
Dilatation and tortuosity of the affected venous segment
Flame-shaped and dot/blot haemorrhages
Cotton wall spots
47
RFs for retinal veins occlusion
• Age is most important factor. Over 50% of cases occur in older than 65
• HTN is present in two-thirds or more of RVO patients over the
age of 50 years and in 25% of younger patients
• Hyperlipidaemia is present in one-third or more of patients, irrespective of age
• Diabetes mellitus is present in up to 15% of patients over 50 years of age
• Glaucoma and ocular HTN
• Oral contraceptive pill In younger females
• Chronic renal failure
• Thyroid diseases
48
HTN causes what type of retinal veins enlarge occlusion
It is a particularly important risk factor in patients with BRVO
49
Glaucoma and ocular HTN associatedwith which type of retinal vein occlusion
Higher risk of CRVO
50
Most important RFs for developing RVO
66% of cases HTN
33% of cases Hyperlipidemia
15% of cases DM
51
52
Rx of RVO
ببساطة سيطر على مسبب المرض وانطي ابر بالعين اما anti vegf او steroids
واذا اكو new vessels سوي ليزر
53
Signs of retinal artery occlusion
Central retinal artery occlusion ~> Pale retina (atrophy)
Cherry red spot
54
Best thing to do for patients with retinal artery occlusion
Cardiologist referral
55
Grades of hypertensive eye disease
• Grade 1~> Mild generalized retinal arteriolar narrowing
• Grade 2 ~> Focal arteriolar narrowing and arteriovenous nipping
• Grade 3 ~> Grade 2 + retinal haemorrhages (dot, blot, flame), exudates (macular star) and cotton-wool spots
• Grade 4 ~> Severe grade 3 + optic disc swelling, which is marker of ‘malignant’ hypertension
56
In what grade we see copper wiring’ opacified appearance of arteriolar walls in hypertensive eye disease
Grade 2
57
chronic retinal oedema may result in the deposition of hard exudates around the fovea as … in grade 3 hypertensive eye disease
Macular star
58
Screening indications for retinopathy of prematurity
Babies born at or before 30–32 weeks gestational age
Babies weighing 1500 g or less
Severe illness in other premature babies
59
How to screen for retinopathy of prematurity
Screening should begin 4–7 weeks postnatally
Subsequent review is at 1–3-week intervals
Continuing until retinal vascularization is complete
60
Rx of retinopathy of prematurity
• Intravitreal anti-VEGF agents
• Laser ablation of avascular peripheral retina
• Pars plana vitrectomy for tractional RD not involving the macula
61
Classification of agre related macular degeneration (AMD)
Dry (non-exudative, non-neovascular) AMD ~> 90% of cases
Wet (exudative, neovascular) AMD is much less common than dry, but is
associated with more rapid progression to advanced sight loss
62
شتسوي لواحد عنده Dry AMD
يسبب progressive vision loss ومتكدر تسويله شي لكن اكو ينطون vitamin A وياه زنك ونحاس وبعد فيتامينات ومعادن وهذا يقلل vision loss بنسبة 25% على اعتبرها مضادات اكسدة
63
شتسوي لواحد عنده Wet AMD
هذا يسبب sudden vision loss بسبب عبور fluid خلال retinal pigmented epithelium وتجمعه داخل الشبكية، علاجه يكون ابر داخل العين (anti vegf)
64
What is the advanced stage of dry AMD called
Geographic atrophy (GA)
65
The main clinical entities of wet AMD are
Choroidal neovascularization CNV
66
RFs for AMD
Up to three times greater if a first-degree relative has the disease
Smoking roughly doubles the risk of AMD
High fat intake and obesity
Aspirin
67
Thin, young, tall males with type A personality and associated with steroids use and HTN on renal dialysis with h.pylori infection suffers from unilateral blurring, metamorphopsia
Dx and Rx?
Central serous chorioretinopathy (CSR)
Stop steroids Oral spironolactone (40 mg twice daily), if recurrent ~> PRP
68
Where’s the problem exactly in retinitis pigmentosa
Pigmentary retinal dystrophy, denotes a diverse group of inherited retinal diseases initially predominantly affecting the rod photoreceptors, with later degeneration of cones
69
Has the mode of inheritance relation to severity of symptoms in RP
• RP may occur as a sporadic (simplex) disorder, or be inherited in an AD, AR or XLR pattern
• XLR is the least common but most severe form and may result in
complete blindness by the third or fourth decades
70
Triad to diagnose RP
Classic triad of:
* Bone spicule (الشبكية منقطة)
* Arteriolar attenuation (الأوعية الدموية صغيرة)
* Disc pallor (waxy disc)
71
Complications of RP
Open-angle glaucoma (3%)
keratoconus (uncommon)
Posterior vitreous detachment
Intermediate uveitis
Exudative retinal detachment
So, annual follow up is recommended
72
Rx of RP
يعني ماكو علاج معين للمرض لكن ممكن نعالج الي يصير وياه مثلا cataract او glaucoma وكله يوقف التدخين وانطيه high dose vitamin A
73
RP + CMO treatment
Oral acetazolamide and sometimes topical carbonic anhydrase inhibitors
74
What’s retinal detachment
RD refers to separation of the neurosensory retina (NSR) from the RPE
75
What’s rhegmatogenus RD
Rhegmatogenous (Greek rhegma – break) RD requires a full-thickness defect in the sensory retina, which permits fluid derived from (liquefied) vitreous to gain access to the subretinal space
Occurs in myopic patients
76
What’s tractional RD
Tractional RD. The NSR is pulled away from the RPE by contracting vitreoretinal membranes in the absence of a retinal break
The main causes of tractional RD are proliferative retinopathy secondary to
diabetes, retinopathy of prematurity and penetrating posterior segment trauma
77
What’s exudative RD
Exudative (serous, secondary) RD. SRF is derived from the vessels of the NSR and/or choroid
Exudative RD occur in a variety of vascular, inflammatory and neoplastic diseases involving the retina, RPE and choroid
78
What are the types of RD
Rhegmatogenous
Exudative
Tractional
79
Sx of RD
• Flashing lights (photopsia)
• Floaters
• Blurred vision
80
Rx of RD
• Scleral buckling or pars plana vitrectomy
81
What’s Posterior synechiae
Inflammatory adhesions between pupil margin and anterior lens capsule
82
What’s uveitis
Inflammation of uveal tract (iris, ciliary body and choroid)
83
Anatomical classification of uveitis
1- Anterior uveitis include iritis and iridocyclitis
2- Intermediate uveitis inflammation of vitreous predominantly
3- Posterior uveitis include retinitis, choroiditis & vasculitis
4- Panuveitis if inflammation involves all uveal tracts
84
Clinical classification of uveitis
1- Acute uveitis present with sudden onset & limited duration (< 3 months)
2- Recurrent uveitis repeated episodes separated by periodnof inactivity
3- Chronic uveitis persistent inflammation more than 3 months
85
What’s Masquerade uveitis
Masquerade: neoplastic and non-neoplastic
Causes ~> Retinoplastoma - Lymphoma - Chronic retinal detachment
86
How visual acuity affected in AAU
Visual acuity is variably impaired depending on the severity of inflammation and the presence of complications. frequently only mildly reduced in AAU
87
HLA-B27 make up the most cases of acute anterior uveitis
No, idiopathic forms make up the largest proportion
88
What’s ciliary injection
Perilimbal injection, ciliary flush or just ‘injection’ is circumcorneal conjunctival hyperaemia with a violaceous (purplish) hue due to involvement of deeper blood vessels
Typically seen in anterior uveitis of acute onset. Ciliary injection is characteristically absent in some forms of CAU and occasionally AAU
89
Why do miosis occurs in AAU
Due to pupillary sphincter spasm predisposes to formation of
posterior synechiae
90
What’s hypopion
Hypopyon refers to a whitish purulent exudate composed of myriad inflammatory cells in the inferior part of the anterior chamber
91
How IOP affected in cases of uveitis
Commonly ~> reduced as the result of impairment of aqueous secretion by the
ciliary epithelium
Rarely increased due to herpes or lens induced uveitis
92
Why posterior segment examination is mandatory in uveitis?
To detect masquerading causes of anterior uveitis, primary intermediate or posterior segment inflammation and complications of such as CMO
93
What’s koeppe nodules and mutton fat koeppe nodules
KP nodules ~> Small, white nodules in acute cases
MF KP nodules ~> Larger and darker in chronic cases such as TB
94
When to order investigations for uveitis
Recurrent - Severe - Bilateral AAU
Persistent, chronic or resistant to treatment
Intermediate or posterior uveitis
Systemic clinical features suggesting underlying disease
Granulomatous inflammatory signs
95
Rx of uveitis
• Steroid
• Cycloplegic
• Antimetaboliate
• Immune modulaters
96
97
What are cycloplegic agents
Cyclopentolate (6h)
Tropicamide (24-48h)
Atropine (3wks)
98
Type of uveitis which’s chronic non granulomatous anterior uveitis with insidious onset typically affect one eye of adults with blurred vision due to complications (cataract and glaucoma) and absent posterior synechiae
Fuchs uveitis syndrome
99
What are the complications of Fuchs uveitis syndrome
Cataract and glaucoma
100
M/C systemic disease associated with childhood anterior uveitis with a prevalence of about 1:1000
JIA
101
… is a key cause of morbidity in JIA. It is particu-larly common in oligoarticular JIA
Anterior uveitis
102
Why uveitis in JIA dangerous
It’s asymptomatic and must generally be detected by screening with slit lamp
Injection is usually absent even in the presence of severe uveitis
Both eyes are affected in 70%
103
Cx of JIA
• Posterior synechia
• Band keratopathy
• Cataract
• Glaucoma (common)
• Amblyopia
• CMO
104
105
Screening for JIA
• Initial examination within 6 weeks of first diagnosis
• Initial 2-monthly exam for 6 months may be considered 3–4 monthly intervals
• Review should continue in most cases until the age of 12 years
106
Prognosis of JIA
• In about 10% the uveitis is mild and persists for less than 12 months
• About 15% of patients have one attack lasting less than 4 months
• In 50% of cases, uveitis moderate - severe and persists for > 4 months
• in 25%, the uveitis is very severe, lasts for several years and responds poorly
107
اشياء اذا موجودة نكول هذا uveitis راح يكون سيء جداً في مرضى JIA
Oligoarticular disease,
ANA +
Onset before 7 years of age
Female gender
108
3 diseases present with uveitis with white eye
Fuchs - Juvenile - Behcet
109
Recurrent bilateral acute ant. Uveitis usually bilateral & associated with mobile hypopyon in relatively white eye, Dx?
Behcet disease
110
Syphilis ocular involvement occurs in secondary or tertiary syphilis, so in patients with uveitis we should order
VDRL
111
Uveitis + Iris nodules =
Leprosy
112
Viral induced uveitis with high IOP
• H. simplex anterior uveitis with trabeculitis that may cause high IOP
• Herpes zoster ant. Uveitis causing chronic granulomatous anterior
uveitis, Sectoral iris atrophy may be seen due to occlusive vasculitis
113
Patient presents with unilateral sudden onset of floaters, visual loss and photophobia
Signs: spill-over ant. uveitis & post. retinal lesion (retinitis or pigmented scar)
Toxoplasma retinitis
114
Visual loss may occur in toxoplasma retinitis as result of
• Involvement of macula
• Secondary optic nerve head involvement
• Occlusion of major vessels by inflammation
• Severe vitritis
115
Toxoplasma retinitis + Visual loss, Rx?
• Drugs used include clindamycine, azithromycine, co-trimaxazole and
sulphadiazine with or without steroid for 4-6 wks
116
Sclera unlike cornea not transparent due to
Collagen bundles of varying size and shape that are not uniformly orientated as in the cornea and so are not transparent
117
How vascular layers arranged in sclera
• Conjunctival vessels are the most superficial
• Superficial episcleral plexus vessels are straight with a radial configuration
In episcleritis, maximal congestion occurs at this level
• Deep vascular plexus lies in the superficial part of the sclera and shows maximal congestion in scleritis
118
How topical phenylephrine works
Topical phenylephrine 2.5% will constrict the conjunctival and 10% of superficial episcleral vessels
119
Female presented with sudden redness with interpalpebral distribution & discomfort with sense of hotness but with no pain
Dx?
Simple Episcleritis
120
Rx of simple episcleritis
• Topical steroid
• Cold compress
• Lubricant
• Systemic NSAID
121
• Female presented with subacute onset & more prolonged course of red eye
typically noted on waking then redness increase (in size but same position)
• Pain, discomfort & tenderness increase with time
Dx?
Nodular episcleritis
122
Ocular redness progressing a few days later to pain that may radiate to the face and temple
The discomfort typically wakes the patient in the early hours of the morning, improves later in the day
Responds poorly to common analgesics
The vision may be blurred
Dx?
Scleritis
123
Scleritis vs Episcleritis
Scleritis ~> Painful - Vision is affected - Redness doesn’t resolve with decongestant drop
Episcleritis ~> Painless - Vision not affected - Redness resolve with decongestant drop
124
Scleromalacia perforans (necrotizing without inflammation) occurs in
RA
125
The globe located in the … , nearer to roof & lateral wall occupying only … of the orbital cavity the orbit fill with fat ,fascia ,septa ,EOM ,orbital nerves and vessels
Anterior orbit — One-fifth
126
Defect in orbital roof may cause
Pulsatile proptosis
127
Orbital roof consist of tow bones: lesser wing of … and orbital plate of … bones
Located subjacent to … and …
Sphenoid - Frontal
Anterior cranial fossa — Frontal sinus
128
Pulsatile proptosis occurs due to
Defect in orbital floor in cases of:
- Neurofibromatosis type 1
- Trauma & Tumours
129
Eyeball more vulnerable to trauma laterally due to
Anterior of the globe protrude more than lateral wall
130
Lateral orbital wall consists of what bones
Greater wing of sphenoid & Zygomatic bones
131
The floor of the orbit consist of three bones, what are they?
Zygomatic ,maxillary & palatine bones
132
Why maxillary carcinoma may invading orbit cause displacing globe upward
Floor of the orbit forms the roof of maxillary sinus
133
What part of orbital floor commonly involved in blow-out fracture
Posteromedial portion of maxillary bones is relatively weak
134
What bones form the medial orbital wall
Sphenoid
Maxillary
Ethmoid
Lacrimal
135
What separate medial orbital wall from ethmoidal sinus
Lamina papyracea
136
Infection may spread from ethmoidal sinus to orbit result in orbital cellulites through what structure?
Lamina papyracea that’s perforated by many nerves & blood vessels
137
The orbit filled with
Globe, Fat ,fascia ,septa ,EOM ,orbital nerves and vessels
138
Superior orbital fissure found in between
Greater and lesser wings of sphenoid
139
What pass through superior orbital fissure (المجاهد الشيعي)
LFT SIOV SSINA (لفت سيوف السنة)
A- lacrimal nerve
B- frontal nerve
C- trochlear nerve
D- superior and inferior ophthalmic veins
E- superior & inferior divisions of oculomotor nerve
F- abducent nerve
H- nasociliary nerve
F- sympathetic nerves
140
All recti muscles originate from
Tendinous ring of zinn
141
How the lid moves up (eyes get opened) ?
Levator palpebral superioris, supplied by superior division of oculomotor nerve
Muller muscle (smooth, inferior to levator) is supplied by sympathetic nerve
142
How lid moves down (eyes get closed) ?
Orbicularis muscle supplied by facial nerve
143
The lid consists of what? (From front to back)
Skin - Subcutaneous areolar tissue - Striated muscle layer
Submuscular areolar tissue - Tarsal plate & fibrous tissue - Conjunctiva
144
Eyelid skin recovers rapidly after edema or trauma
Because it’s thin & very elastic
145
Striated muscle layer of the eyelid formed by
Palpebral part of orbicularis oculi muscle, it’s fibers encircle palpebral opening
146
Local anesthesia should be injected deep to orbicularis
Because palpebral nerves lie in Submuscular areolar tissue that lies between orbicularis & tarsal plate
147
Superior vs Inferior tarsal plates
Superior tarsus is larger (11 mm in height) than in inferior tarsus (5mm in height) with equal thickness of 1mm and length of 29mm
So, they differ only in height
148
Medial and lateral palpebral ligaments function
Ends of both plates are attached to orbital margin by them
149
Modified sebaceous gland located in tarsal plate & secret lipid layer of tears through orifices open in lid margin
Meibomian gland
150
Anterior to orifices of meibomian gland lie grey line which separate
Posterior lamella (conjunctiva & tarsus) from anterior lamella (skin & muscle)
151
What’s the grey line
Anterior to orifices of meibomian gland lie grey line which separate posterior lamella (conjunctiva & tarsus) from anterior lamella (skin & muscle)
152
Lymphatic of eyelids
Preaucular & submandibular lymph nodes
153
Where we can find the conjunctiva
It lines inner surface of the eyelids & surface of globe as far as limbus where it continuous with corneal epithelium
154
What’s the limbus
Junction between sclera and cornea, covered by conjunctiva
155
What’s tenon capsule
Thin fibrous layer separate conjunctiva from sclera
156
What cells can we find in the conjunctiva
Goblet cells (mucous secreting glands)
Accessory lacrimal glands
Lymphatic cells which is form follicular reaction in certain conditions
(these cells not develop before 3 months age)
157
Division of conjunctiva
Palpebral ~> Firmly adhered to tarsal plate
Fornicial ~> Loose & redundant & may be folded
Bulbar ~> Loosely adherent to tenon capsule
158
Site and function of lacrimal gland
Lacrimal gland Lie above & anterolateral to the globe
Secret aqoues layer of tears through series of ducts into superior fornix
159
Lacrimal gland secret aqoues layer of tears through series of ducts into
Superior fornix
160
How lacrimal gland divided
Superior orbital and Inferior palpebral part separated by levator appounorosis
161
What are the accessory lacrimal glands within conjunctiva contribute to less extent in tears production
Accessory lacrimal glands of krause & wolfring
162
Why conjunctiva called الملتحمة
Connect eyeball to the lid
163
Function of accessory lacrimal glands
Basal lacrimal secretions
164
What are the puncti
Tow openings located at post. edge of lid margin at junction of lashes
Can be inspected by averting medial aspect of lid
165
Canaliculi of lacrimal drainage system
Pass vertical from lid margin for about 2 mm then turn medially &run horizontally for 8mm to reach lacrimal sac
166
What’s valve of rosenmuller
Small flab of mucosa overhang junction of common canalicului & lacrimal sac to prevent reflux of tears into canaliculi
167
Site of lacrimal sac
Lacrimal sac is about 10 mm long & lie in lacrimal fossa between ant. & post. lacrimal crest
168
How lacrimal sac separated from middle meatus
By lacrimal bone & frontal process of maxillary bone
169
Where nasolacrimal duct opens
It’s about 12 mm long, its continuation of lacrimal sac, descend slight laterally &
posteriorly to open into inferior nasal meatus lat. & inf. to inferior turbinate
170
What’s valve of hasner
Mucosal fold that covers opening of nasolacrimal duct
171
Origin of recti muscles
Common annulus at orbital apex
172
Insertion of recti muscles
MR ~> insert anteriorly 5.5 mm behind nasal limbus
IR ~> inserted 6.5 mm behind inf. limbus
LR ~> inserted 6.9 mm behind temporal limbus
SR ~> inserted 7.7 mm behind sup. limbus
173
All recti are … and all superiors are …
Adductors … Intortors
174
Superior & Inferior obliques origin
SO ~> Originate superomedial to optic foramina pass forward through trochlea (ring like cartilage at superomedal orbital wall) then it reflected backward and laterally
IO ~> Originate from small depression just behind orbital rim lateral to lacrimal
sac, it pass backward & laterally
175
Insertion of obliques
SO ~> Insert in the posterior upper temporal quadrant of the globe
IO ~> Insert in posterior lower temporal quadrant of globe (close to macula)
176
Normal adult globe approximately spherical with AP diameter averaging …
24mm
177
Globe divided into 3 layers, what are they?
1- Outer fibrous layer it is most taught consist of cornea ant. & sclera post.
2- Middle vascular layer consist of iris ,ciliary body & choroid
3- Inner neural layer: the sensory retina
178
The thickness at center about … more at peripheral near the limbus ,average horizontal diameter … ,vertical …
0.5 mm — 12 mm — 11.5mm
179
Epithelium of the cornea
Stratified non keratinized squamous epithelium
180
Can corneal epithelium regenerate?
Yes, from limbal stem cells
181
Acellular superficial layer of stroma of the cornea is
Bowman layer
182
What make about 90 % of corneal thickness composed of regularly oriented layers of collagen fibrils and keratocytes?
Corneal Stroma
183
Layer in the cornea composed of lattice work of collagen fibrils
Desecmet membrane
184
What’s corneal endothelium
It’s single layer of hexagonal cells playing vital role in corneal detergence ,it not capable of regeneration like corneal epithelium
185
What’s the most densely innervated tissue in the body
Cornea
186
Sensory supply of the cornea
1st dividion of CN V = Opthalmic
187
What structures pass through inferior orbital fissure
Inferior ophthalmic vein
Infra-orbital (nerve - artery - vein)
Ganglionic branches from pteregopalatine to maxillary nerve
Zygomatic nerve
188
Layers of the cornea
A B C D E
Anterior epithelial layer
Bowmen’s capsule
Corneal stroma
Desecmet membrane
Endothelium
189
Define sclera
Fibrous outer protective coating of eye, consist almost entirely of collagen ,its dense ,white in color continuous with cornea anteriorly & with dural sheath of optic nerve posteriorly , covered by episclera
190
Thickness of sclera
From 0.3 to 1mm
191
Layers of sclera
Episclera
Stroma
Lamina fusca
Endothelium
192
Inner layer of sclera called
Lamina fusca blend with suprachoroidal and supraciliary lamellae
193
Anterior chambers boundaries
Cornea anteriorly — Lens & iris posteriorly
Average depth is 3mm & volume about 250ul
194
Pathway of aqoues which secreted from ciliary body
Pass to AC and drain through trabecular meshwork then through sclemn canal to episcleral veins
195
Corneoscleral limbus consist of
Trabecular meshwork ,sclemn canal & sclera spur
196
What’s surgical limbus
Conjuctivocorneal junction is anterior to anatomical limbus (about 1mm)
197
The iris lined by
Pigmented epithelium
198
The iris lies between
Anterior & Posterior chambers
199
Diameters of iris
Diameter approximately 12mm ,its thickness at mid-zone about 0.6mm & is thinnest at iris root(its periphery)
200
The ciliary body which is triangular in cross section divided into
Anterior zone ~> pars plicata which is corrugated about 2mm, contain ciliary processes which secret aqueous
Posterior zone ~> pars plana flat about 4mm
Stroma contain ciliary muscle which are of three types longitudinal ,circular & oblique muscles
201
Ciliary epithelium, the external is … and internal is …
Pigmented & Internal non pigmented
202
Where’s the choroid
Between retina and sclera
202
203
What’s lamina fusca
Inner layer of sclera that seperates choroid from sclera
204
What’s bruch's membrane
Separates choroid from retina
205
Anterior and poste attachments of choroid
Posteriorly optic nerve
Anteriorly ciliary body
206
Outer 1/3 of retina (outer 5 layers) supplied by
Inner small fenestrated blood vessels (choriocappilaries)
207
Venous drainage of choroid to
Cavernous sinus
208
What part of ciliary muscle responsible for accommodation
Circular
209
The … part of ciliary muscle when it contracts the ciliary spur will be pulled to open schlem canal and increase drainage of aqueous humour
Longitudinal
210
Define lens
Biconvex avascular transparent, about 4 mm thickness & 9mm in diameter
211
What part of lens formed later in life
Nucleus
212
Site of vitreous humor
It fills posterior four fifth of the globe in contact with retina in behind & ciliary body and zonules in front
213
Composition of vitreous humor
It composed 99 %of water ,other content is collagen network
214
Volume of vitreous
About 4ml
215
RPE loosely attach to sensory retina except at
Optic disc & Orra serrata
216
Colour of macula
Yellow because it contains yellowish xanthophylls pigment
217
Clinical macula lie between
Temporal and nasal retinal vascular arcades about 4mm lateral to disc margin
218
Optic nerve emerge from posterior surface of globe through …
Posterior sclera foramina
219
How myelination change the optic nerve diameter
From 1.5mm to 3mm
220
Parts of optic nerve
a) Intraocular part (optic disc ,optic nerve papillae) appear in fundoscopy, it oval in shape with vertical diameter about 1.5mm, it very short length about 1mm
b) Intraorbital part about 3cm extend from globe to optic foramina
c) Intra canalicular part in optic canal about 6mm
d) Intracranial part about 1cm
221
Part of optic nerve detected by fundoscopy
Intra-occular part (optic disc)
222
Depression in the centre of optic disc surround by neuroretinal rim
Optic cup
223
Pain , photophobia & foreign body sensation suggest … involvement
Is it conjunctivitis?
Corneal
224
Hallmark of allergic conjunctivitis, although it may occur in dry eye or blephritis
Itching
225
Types of discharge in conjunctivitis
- Watery discharge occur in acute viral or acute allergic conjunctivitis
- Mucoid discharge chronic allergic conjunctivitis and dry eye
- Mucopurulent discharge in acute bacterial or chlamydial infection
- Purulent discharge typical of gonococcal infection
226
Types of conjunctival reaction
- Follicular reaction is represent lymphatic and seen as multiple discrete
yellowish slightly elevated lesions
- Papillary reaction develop only in palpebral conjunctiva & limbal bulbar conjunctiva , it seen as elevated red dots , it represent hyperplastic conj. epithelium with fibrovascular core
227
Causes of follicular conjunctival reaction
- Viral conjunctivitis
- Chlamydial conjunctivitis
- Drugs toxicity
228
Causes of papillary conjunctival reaction
- Acute bacterial conjunctivitis,
- Allergic conjunctivitis
- Contact lens wear
229
Follicular conjunctival reaction occurs only after age of …
3 months
230
Site and colour on conjunctival injection (congestion)
Diffuse, beefy red away from limbus (most intense in fornicial conj.) as in bacterial conjunctivitis
231
Types of membranes in conjunctivitis
Pseudo-membrane consists of coagulated exudates & may easily peeled leaving
epithelium intact
True membrane infiltrate conj epith. & attempting to remove may lead to
conj. epith. tearing & bleeding
232
Patient presented with presented acute onset of redness ,grittiness ,burning & discharge. Initially one eye affected 1-2 days before other ,on waking eyelids stuck together & difficult to open
O/E diffuse conj congestion ,intense papillary reaction over tarsal plate ,discharge initially watery but later become mucopurulent
Simple bacterial conjunctivitis
233
Causes of simple bacterial conjunctivitis
Staph & Strept
234
Rx of simple bacterial conjunctivitis
60% of cases resolve within 5 days without treatment
235
Patient presented with acute profuse purulent conj. discharge
O/E severe eyelid oedema & tenderness with intense conj. hyperemia, chemosis, pseudomembrane formation, lymphadenopahy, and corneal involvement in form of peripheral ulceration that then extend centrally & cause perforation
Gonococcal kerato-conjunctivitis caused by Neisseria gonoorrhoea
236
Can lymphadenopathy occurs in cases of conjunctivitis
Yes, in cases of viral, chlamydial & gonnococcal infection
237
Rx of gonococcal conjunctivitis
Topical gentamycin or bacitracin initially hourly & systemic IM ceftriaxone 250 mg daily for 3 days
Or
Ceftriaxone 1 gm stat and if corneal involvement, hospitalisation with more aggressive treatment 2g IV for 3 days
238
Patient presented with acute conjunctivitis associated with subconj. haemorrhage, lymphadenopathy, keratitis with ulceration & perforation
Meningococcal conjunctivitis caused by N. meningitides
239
Rx of Meningococcal conjunctivitis caused by N. meningitides
Topical penicillin or cefitaxime drops
240
Patient presented with subacute onset of bilateral redness, watering & mucopurulent discharge, follicles, lymphadenopathy
Adult chlamydial conjunctivitis caused by chlamydial sp.
241
Rx of Adult chlamydial conjunctivitis caused by chlamydial sp.
- Topical erythromycin or tetracycline ointment
- Systemic doxycycline 100 mg twice for 10 days
242
Currently the leading cause of preventable blindness in world specially in poor overcrowding societies is …
Trachoma
243
Patient presented with mixed follicular & papillary conjunctivitis associated with mucopurulent discharge and conjunctival scarring
Trachoma
244
Cx of trachoma
1- Trichiasis
2- Distichiais
3- Corneal vascularization & corneal opacification (cause of blindness)
4- Cicatricial entropion
5- Dry eye due to destruction of goblet cells & lacrimal glands ducts
245
Rx of trachoma
Prevention involve regular face washing & control of flies (which is vector)
Antibiotics either systemic Azithromycin or erythromycin better than topical
Surgery for relieving trichiasis or entropion
246
Causes of Ophthalmia Neonatorum (neonatal conjunctivitis)
1- N . gonorrhea uncommon but serious more in developed countries
2- Chlamydia trachomatis common may cause otitis, pneumonia..
3- Other pathogens include staph. , strept. , H. influenzae and herpes
247
Neonate between 3-19 days after birth as bilateral eyelid oedema & mucopurulent discharge & papillary reaction with pseudomembrane, corneal ulcer & conj. Scaring & peripheral corneal pannus
Ophthalmia Neonatorum (neonatal conjunctivitis)
248
Prophylaxis against Ophthalmia Neonatorum (neonatal conjunctivitis)
Prophylaxis with povidine iodine 2.5 % is effective
Single application at birth is sufficient against most pathogens
249
Transmission of adenovirus regarding conjunctivitis
The transmission of highly contagious virus is by respiratory or ocular
secretions & dissemination by contaminated towels or equipment such tonometry & by hand to eye contact
250
Spectrum of adenovirus infection regarding conjunctivitis
Pharyngo-conjunctival fevor ~> keratitis occur in 30 % but mild
Epidemic kerato conjunctivitis ~> keratitis occur in 80% & may be sever
251
Patient presented with unilateral watering, redness, discomfort & photophobia
Other eye affected 1-2 days later
O/E eyelid oedema, tender LAP, follicular conjunctivitis, subconj. hemorrhage, chemosis & pseudo membrane
Keratitis, started as punctuate epithelial keratitis within first week of
symptoms & resolved within 2 weeks
Adenoviral kerato-conjunctivitis
252
Rx of kerato-conjunctivitis
Artificial tears ,cold compress until spontaneous resolution occur within 3 wks
Topical steroid for sever membranous conjunctivitis & for keratitis
253
Child with chronic unilateral ocular irritation & mild discharge, we can see lid
nodule at margin (pale, waxy & implicated) with follicular conjunctivitis
Molluscum contagiosum conjunctivitis
254
Rx of Molluscum contagiosum conjunctivitis
Removal of primary lesion for cosmetic reason or to treat 2ry conjunctivitis
255
Causes and Rx of Acute hemorrhagic conjunctivitis
Caused by enterovirus or coxsackievirus
No treatment need just control to prevent spreed
256
Contact lenses wear usually predispose to bacterial keratitis by
Pseudomonas species
257
Which part of the eye get infected when there’s vitamin A deficiency
Cornea
258
Bacteria that can invade normal corneal epithelium are
N.gonorhea ,N. mengitidis , C. diphtheria & H.influenza
259
Diseases of cornea are … while conjunctiva are …
Painful — Painless
260
Patient presented with pain ,photophobia and blurred vision
O/E epithelial defect with infiltrate, stromal odema & hypopyon & ulceration &
perforation & scleritis limbus, progress of infection to endophthalmitis
Bacterial keratitis
261
Rx of bacterial keratitis
- Topical ABx: dual therapy with high concentration such genidine or cephazoline
- Oral Antibiotics in form of ciprofloxacine ,if poor compliance to topical
- Cycloplegics to relieve CB spasm
262
What type of keratitis commen in tropical & developing countries at account 25% of keratitis
Fungal
263
Trauma to the eye with vegetables lead to what type of kertatitis
Fungal
264
What type of keratitis leads to severe inflammatory response lead to stromal necrosis & melting
Fungal
265
Patient presented with gradual onset of foreign body sensation, photophobia,
blurred vision & discharge
O/E mild redness & mild lid swelling with grey yellow or yellow white infiltrate in
stroma with indistinct margin ,hypopyon & stromal suppuration
Fungal keratitis
266
Rx of fungal keratitis
- Topical antifungal treatment such as Natamycine 5% or amphotracine 0.2%
- Broad spectrum antibiotic for co infection
- Epithelial scraping removal of corneal epithelium to decrease fungal load & enhance topical antifungal therapy
— Subonjunctival fluconazole for severe case
— Systemic antifungal for sever keratitis or endopthalmitis
* Exicional penetrating keratoplasty may be required in unresponded cases *
267
When to suspect fungal keratitis
Keratitis that fails to respond to ABx
Trauma with organic materials
268
What’s Acantheameba keratitis
Type of keratitis caused by free living protozoa commonly found in soil or water
269
Patient presented with blurred vision & pain that’s inconsistent with clinical presentation
O/E epithelial pseudodendritic , limbitis ,perinueral infiltrate
Along with scleritis, corneal melting & stromal opacification & vascularization
Acantheameba keratitis
270
Pathognomonic signs of Acantheameba keratitis
Epithelial pseudodendritic
Limbitis
Perinueral infiltrate
271
Rx of Acantheameba keratitis
1-Depridment
2- Topical amebocide
3- Pain control
4- Keratoplasty for residual scar
272
What’s the major cause of unilateral corneal scaring worldwide
Herpes simplex
273
Most common cause of infectious blindness in developed countries
Herpes simplex
274
Patient presented with epithelial (dendritic) keratitis with mild discomfort, watering & blurred vision
O/E central desquamation result in linear branching ulcer located centrally, stained with flouroscine
Corneal sensation is reduced , mild subepithelial scar may occur
After using of topical steroid there’s progressive enlargement of ulcer give geographical or ameboid figure
Herpes simplex keratitis
275
Keratitis + After using of topical steroid there’s progressive enlargement of ulcer give geographical or ameboid figure
Herpes simplex
276
Herpes simplex keratitis + Topical steroids
Progressive enlargement of ulcer give geographical or ameboid figure
277
Differential disgnosis of dendritic corneal ulcer
1- Herpis zoster keratitis
2- Healing corneal abrasion (psuedodendritic )
3- Acanthaemeba kertaitis
4- Toxic keratopathy secondary to topical medication
278
Patient presented with blured vision & haloes
O/E stroamal odema, Keratic precipitate , Folds in descmet membrane and anterior uveitis
Disciform keratitis its due to hypersensitivity reaction to viral antigen in cornea
279
Rx of disciform keratitis
Steroids after making sure there’s no dendritic corneal ulcer & Antiviral therapy
280
Rx of herbes zoster keratitis
Topical antiviral as acyclovir as ointment 5 times dially
Depridment
281
pathogenisis of ocular involvemen in herpes zoster opthalmicus
- Direct invasion cause epithelial keratitis and conjunctivitis
- Secondary inflammation and occlusive vasculitis cause:
a- Episcleritis
b- Scleritis
c- Uveitis
d- Stromal keratatis
e- Neurotrophic keratatis
282
Percentage of eye involvement after varicella zoster infection
Eye involvement occur in i about 50% of patient within 2 days of onset of rashes & resolve spontaneously within few days in acute stage
283
What happens to the eye in cases of chronic varicella zoster infection
- Lid scaring may result in
Ptosis , Cicatricial entropion , Trichiasis , Madarosis notching of lids
Neurotrophic keratitis , reduced corneal sensation
284
Rx of herpes zoster opthalmicus
1- Systemic antiviral
2- Topical antiviral
3- For neuralgia give Analgesia like codeine , amitriptyline or carbamazepine
285
Causes of decreased corneal sensation (neurotrophic keratitis)
Damage to 5th cranial nerve such as surgery stroke, aneurysm and tumours
Systemic diseases like DM or leprosy
Herpes simplex keratitis, VZ keratitis
Topical anaesthesia abuse
Refractive corneal surgery
Familial dysautonomia
286
Patient presented with decrease corneal sensation ,punctuate keratopathy in interpalpebral zone, persistent epithelial defect, stromal corneal melting
Neurotrophic keratitis
287
Rx of neurotrophic keratitis
Topical lubricant (for associated dry eye & exposure)
Protection of ocular surface by taping ,tarsorhaphy or contact lenses
288
Exposure keratitis
Type of keratitis due to lagophthalmus that results in dry eye with normal tear production
289
Causes of exposure keratitis
Neuroparalytic such as acial nerve palsy
Reduced muscle tone such as coma or parkinsonism
Mechanical as in eyelid scaring associated with burn or tumours
Abnormal globe position like sever proptosis or sever endopthalmus
290
5th cranial palsy cause … keratitis
7th cranial nerve palsy cause … keratitis
Neurotrophic — Exposure
291
Rx of exposure keratitis
Transient (reversible) ~> treated by artificial tears, taping, contact lenses
For permanent exposure ~> permanent tarsorhaphy or conjunctival flab
292
What’s the filamentary keratitis
Results from deposition of mucous & cellular debris in loose area of epithelium
293
Causes of filamentary keratitis
Dry eye is most common cause
Corneal epithelium instability as in cataract surgery or corneal graft
Neurotrophic keratitis
Prolong occlusion such as eye patching
294
M/C cause of filamentary keratitis
Dry eye
295
Keratitis after cataract surgery
Filamentary keratitis
296
Keratitis after corneal graft
Filamentary keratitis
297
Keratitis after coma
Exposure keratitis
298
Keratitis after burn
Exposure
299
Keratitis after stroke
Neurotrophic keratitis
300
Neurotrophic keratitis leads to what type of keratitis
Filamentary keratitis
301
Patient presented with eye discomfort and forign body sensation
O/E strands of degenerating epithelial cells with mucous attach to cornea & move during blinking and that stained with Rose-Bengal stain
Filamentary keratitis
302
Rx of filamentary keratitis
Treatment of underlying cause
Stop medication, steroid
Removal of filaments
Mucolytic agent
Bandage contact lenses
303
Normal corneal thickness
500 micrometers
304
In keratoconus, the cornea assume conical shape secondary to
Stromal thinning
305
Why there’s impairment of vision in keratoconus
Due to high myopia & irregular astigmatism
306
Hallmarks of keratoconus to diagnose are
Central or paracentral stromal thining
Apical protrusion
Irregular astigmatism
Oildoplet reflex seen by direct ophthalmoscopy
Scissor reflex seen by retinoscopy
Vogt lines:- fine vertical deep stria seen by slit lamp
Fleischer ring :- epithelial iron deposition at base of cone
Munson sign :- bulging of lower lid in down gaze
307
In patients with keratoconus, what we see on ophthalmoscope
Oil droplet reflex
308
Oil droplet reflex seen by
Ophthalmoscope in patients with keratoconus
309
In patients with keratoconus, what we see on retinoscopy
Scissor reflex
310
Scissor reflex seen by
Retinoscopy in patients with keratoconus
311
In patients with keratoconus, what we see on slit lamp
Vogt lines ~> fine vertical deep stria
312
Vogt lines seen by
Slit lamp, they are deep vertical striae seen in patients with keratoconus
313
What’s Munson sign
Bulging of lower lid in down gaze
314
Bulging of lower lid in down gaze called
Munson sign
315
Most sensitive method to detecting early keratoconus , montoring progression and shows irregular astigmatism
Corneal topography
316
Keratoconus associated with what conditions
Systemic disorders include Down, marfan, Atopy, Turner
Ocular association: vernal keratoconjunctivitis (chronic allergic), aniridai,
ectopia lentis, retinitis pigmentosa
317
What causes corneal scaring in keratoconus
Stromal scar result from repture of descmet membrane acute hydrops
318
What operation contraindicated in keratoconus
Lasik
319
Rx of keratoconus
Mild refractive error ~> Spectacles
High irregular astigmatism ~> Rigid contact lenses required
Advanced progressive disease with corneal scaring ~> Keratoplasty
320
What’s corneal dystrophy
Group of progressive, bilateral non inflammatory opacifying disorders that present as visual impairment or recurrent erosion syndrome
It classified according to level of abnormalities whether lesion in epithelium ,Bowman's layer ,stroma or endothelium
321
What’s the most common peripheral corneal opacity occur in elderly or may
associated with familial hyperlipidemia
Arcus senilis
322
Why Arcus senilis occurs
Lipid deposition in stroma usually start in superior & inferior perilimbal cornea & then progress to form band about 1 mm
323
White yellow stromal lipid deposition with neovascularisation
Lipid keratopathy
324
What viruses associated with lipid keratopathy
Herpes zoster and Varicella zoster
325
Rx of lipid keratopathy
Argon laser photocoagulation to arterial feeder
Penetrating keratoplasty
326
Deposition of calcium in bowman layer and anterior stroma results in
Band keratopathy
327
Causes of band keratopathy
Age or Hereditary
Anterior uveitis, chronic keratitis or corneal edema
Metabolic causes as hyperurecimia and chronic renal failure
328
Corneal edema occurs with which type of corneal degeneration (keratopathy)
Band keratopathy
329
Rx of band keratopathy
Chelation ~> remove large chips of calcium , scrap corneal epithelium & apply cheating agent like EDTA
Laser keratectomy
Lamellar keratoplasty
330
Rx of band keratopathy & Lipid keratopathy
Lipid ~> Argon laser + Penetrating Keratoplasty
Band ~> Laser keratectomy + Lamellar Keratoplasty
331
Signs of band keratopathy
Peripheral interpalpebral calcification with central spread which forms band like chalky plaques
332
The development of the eye is a complex and rapid process that involves a precise interaction of
Neuroectoderm, surface ectoderm, and mesoderm
333
surfcaeectoderm give rise to
lens, lacrimal gland, corneal epithelium, conj., adenixial gland & lid epidermis
334
Neural ectoderm gives rise to
Retina, RPE, Ciliary epithelium, Iris sphincter, Dilator muscle
Optic nerve & Glia
335
Neural crest give rise to
Corneal keratocyte, Endothelium of cornea, Trabecular meshwork
Stroma of iris and choroid, Cliary muscles, Fibroblast of sclera, vitreous
Optic nerve meninges
336
Mesoderm gives rise to
EOM and orbital ocular vessels
337
Ciliary epithelium and Ciliary muscles arise from
Ciliary epithelial ~> Neural ectoderm
Ciliary muscles ~> Neural crest
338
Sphincter of iris and stroma of iris arise from
Sphincter ~> Neural ectoderm
Stroma ~> Neural crest
339
Optic nerve and glia & optic nerve meninges arise from
Optic nerve and glia ~> Neural ectoderm
Optic nerve meninges ~> Neural crest
340
Embryology of the cornea
Corneal epithelium ~> Surface ectoderm
Corneal keratocytes and endothelium ~> Neural crest
341
Smooth surface of high optical quality of the cornea results from
Blinking action of lid serve to spread of the tear film across cornea
342
Smoothing out irregularities in the cornea is function of
Tear film
343
Primary source of oxygen and nutrition to cornea is function of
Tear film
344
Which’s responsible for
1- Maintain the integrity of corneal surface
2- Maintain normal functioning ocular surface
1- Eyelid
2- Tear film
345
The refractive power of the eye comes from what
2/3 ~> Cornea
1/3 ~> Lens
346
Why cornea is transparent
1-Avascularity
2- Paucity of cells
3- Regularly arranged of uniform fibrils forming the stroma
4- Detergence function of endothelium
347
If cornea is avascular, how it’s supplied
1- Tear film
2- Aqueous humor
3- Limbal vessels
348
The aqueous humor secreted from
Non pigmented ciliary epithelium
349
How large molecule don’t pass to aqueous and it stays clear
Due to Anterior blood ocular barrier
350
Anterior blood ocular barrier formed by
1- Tight junction between non pigmented ciliary epithelium
2- Non leaking iris capillaries
351
Aqueous humor consist of
99% from water ,other substitute sugar, amino acids & ascorbate
352
Avascular ocular tissue such as cornea ,lens & anterior vitreous
Get their nutrition from
Aqueous humor
353
What part of the eye grow in size and weight with life
Lens
354
What part of the eye is avascular & innervation is absent
Lens
355
Accommodation mechanism
Stimulation of ciliary muscle lead to forward displacement of ciliary body
Then relaxation of zonule with forward displacement of the lens
Refractive power increases
356
Ciliary muscles innervated by
Ciliary muscles innervated by parasympathetic cholinergic nerve fibers in which acetyle choline is main receptor
So anticholenergic drugs paralyses the accomadation like atropine
357
Compositions of lens
66% water
33% protein
358
About 80% of globe is
Vitreous (4ml)
359
Tow separate vascular system involve in nutrition of eye
1- Retinal vessels
2- Uveal (ciliary) vessels
360
Arteries of the eye
Posterior ciliary (long - short - medial - lateral)
Central retinal
Lacrimal
361
Central retinal artery which is first branch of ophthalmic artery enter optic nerve ..… & appear at optic disc where it branch into 4 major vessels each one supply quadrant of retina
1 cm behind eyeball
362
Muscles of pupil
a- Sphincter iridis muscle
b- Dilator papillae muscle
363
Innervation of pupil muscles
Autonomic nervous system, dilator by sympathetic ,sphincter by para
364
Pupil size vary from … according to age &amount of light
2.5-6 mm
365
Anisocoria is different between two pupil size & is physiological in … of people
20%
366
Drugs that constrict pupil called miotics like
Pilocarpine,carbachol and metacholine
367
Efferent pupilary defect caused by
Any lesion impair parasympathetic to sphincter like oculomotor nerve palsy
368
Near reflex composed of
Convergence ~> Miosis ~> Accommodation
369
Most common form of ocular and nasal allergy affect about 20% of population
Acute allergic rhino-conjunctivitis
370
Types of acute allergic rhino-conjunctivitis
Seasonal - Perennial
371
Patient presented with acute attack of redness , watering and itching associated with sneezing & nasal discharge, O/E chemosis & mild papillary conjunctivitis
Acute allergic rhino-conjunctivitis
372
Rx of acute allergic rhino-conjunctivitis
Mast cell stabilizer like sodium cromoglycate
Antihistamine for symptomatic patient like levocabastine
Steroid affective but rarely indicated
373
What’s Vernal kerato-conjunctivitis (VKC)
Chronic form of allergic conjunctivitis, it is bilateral recurrent disorder
affect primarily boys , usually present in first decade of life
374
Sites of Vernal kerato-conjunctivitis
Palpebral (involve upper tarsal conjunctiva) ~> this had corneal complication Limbal
Mixed
375
Patient presented with intense itching , lacrimation , photophobia , foreign body sensation, burning & thick mucoid discharge and Constant blinking
O/E diffuse papillary hypertrophy , conjunctival injection , keratoconus
Vernal kerato-conjunctivitis
376
Corneal complications of Vernal kerato-conjunctivitis
A- punctuate epithelial erosions more in superior cornea
B- Epithelial macroerosion
C- Shield ulcer & plaque
D- Peripheral superficial vascularization
E- Increase incidence of keratoconus
377
Rx of Vernal kerato-conjunctivitis
1- Mast cell stabilizer
2- Antihistamine
3- Steroids & Subtarsal steroid injection
4- Systemic immunosuppressant
378
Type of kerato-conjunctivitis associated with visual morbidity due to severe unremitting course
Atopic kerato-conjunctivitis
379
What’s symplepharon
Adhesios between bulbar + palpebral conjunctiva & keratinization of conjunctiva
380
Giant papillary conjunctivitis result from
Mechanical stimuli to tarsal conjunctiva including contact lens, prosthesis & exposed sutures
381
What causes symblepharon
Mucous membrane pemphigoid
Atopic kerato-conjunctivitis
382
Patient presented with papillary conjunctivitis, diffuse hyperemia, symplepharon
blepharitis , keratinization of lid margin , ankyloblepharon, corneal opacification
Mucous membrane pemphigoid
383
Rx of Mucous membrane pemphigoid
Urgent systemic steroid in active diseases & tapering later on
Topical treatment with steroid and artificial tears
Sub Conjunctival Mitomycine injection
Contact lenses
Reconstructive surgery after inflammation had controlled
384
What’s Pinguncula
Yellow white deposit in bulbar conjunctiva
Tx usually unnecessary
Doesn’t cross limbus
385
What’s Pterygium
Triangular fibro vascular sub epithelial growth of degenerative bulbar conjunctiva over limbus into cornea
386
Indications of surgery in pteregium
a- If affect visual axis (large ptregium)
b- If induce astigmatism
c- Cosmetic reasons
387
Recurrence is high in pteregium & if recurs treatment should be with
Injection of 5-flouro uracil (5-FU) or mitomycine or using graft surgery
388
Classification of scleritis
Anterior
o non-necrotizing ~> diffuse or nodular
o necrotizing ~> with inflammation or without
posterior
389
Copper deposition in descmet membrane give rise to
Kyser-Fleischer ring
390
Presenile cataract caused by
Wilson disease
391
Occular complications of mucopolysacharidosis
- Keratopathy ~> Congenital corneal opacity
- Glaucoma
- Optic atrophy
- Pigmentary retinopathy
392
Examples of mucopolysacharidosis
Hurler, Hunter , Morqui
393
How to differentiate between cystinosis and mucopolysacharidosis
Cystinosis ~> Renal Failure
Mucopolysacharidosis ~> Skeletal abnormalities
394
Corneal graft may be:
A- Full thickness (penetrating keratoplasty)
B- Partial thickness (lamellar keratoplasty)
395
Indications for full thickness (penetrating) Keratoplasty
- Optical to improve vision as in corneal dystrophies, keratoconus, scaring,
degeneration
- Tectonic to restore or preserve corneal integrity as in severe stromal thinning and descmatocele
- Therapeutic removal of infected corneal tissue as in eyes not respond to
antimicrobial therapy
- Cosmetics to improve appearance of eyes
396
Indication for partial thickness (lamellar) Keratoplasty
If opacification in anterior cornea such as band keratopathy
397
Conditions for corneal tissue graft
Removed within 24 hours of death
Donor should not be infant (flobby cornea cause high astigmatism)
Donor should not be elderly over 70 years (low endothelial count)
Should not have systemic infections (AIDS , hepatitis , CNS infection ..)
Should not have neoplastic diseases (leukemia, lymphoma…)
Should not have intrinsic eye diseases
398
Why corneal donor should not be infant
Flobby cornea cause high astigmatism
399
Why corneal donor should not be elderly over 70
Low endothelial count
400
What type of Keratoplasty associated with less astigmatism
Lamellar (partial thickness)
401
Cx of corneal graft
1- Persistant epithelial defect
2- Astigmatism
3- Wound leak which may lead to flat ac ,iris prolapse & risk of infection
4- Uveitis with elevation of intraocular pressure IOP
5- Recurrence of initial diseases in the graft
6- Rejection could be from endothelium
402
Rx of corneal graft complications
Intense steroids
403
Adverse factors affect prognosis of corneal graft
- Abnormalities of eyelid such blephritis, ectropion ,entropion ,trichiasis
- Tear film dysfunction
- Chronic conjunctival inflammation such atopic conjunctivitis or pemphegoid
- Uveitis & anterior synachia (adhesion between cornea & iris)
- Active inflammation , stromal vascularization or absence of corneal sensation
- Uncontrolled glaucoma
404
What’s Xerophthalmia
Spectrum of ocular diseases caused by Vit A deficiency which is responsible for many cases of blindness especially in children in developing countries
405
What’s Bitot spot
Triangular patches of foamy keratinized epithelium in interpalpebral zone
406
Triangular patches of foamy keratinized epithelium in interpalpebral zone
Bitot spot seen in xeropthalmia
407
Keratomalacia reflect severe Vit A deficiency & should be treated as medical emergency with
- Oral or I.M vit A , multivitamins supplement & dietary sources of vit A
- Oopical lubricants & topical retinoic acid
408
Types of contact lenses
Hard (rigid) contact lenses
~> either standard H.C.L which impermeable to oxygen & always for daily use
or gas preamble hard C.L which can be used for longer period
Soft C.L
~> either cosmetic C.L
or therapeutic such bandage C.L which use for protection of corneal epithelium
409
Cx of contact lenses
- Mechanical and hypoxic damage to corneal tissue & may cause keratopathy
- Immunological (allergic ) keratitis due to sensitisation
- Toxic keratitis caused by hyper sensitivity from preservative such thiomerasl
- Infective Keratitis : C.L wearer at high risk of bacterial keratitis or acntheameba
- Giant papillary conjunctivitis as in poor fitted C.L
410
External hordeolum (stye)
Acute staphylococcal abscess of a lash follicle and its associated gland of Zeis
411
External hordeolum (stye) treatment
Topical (occasionally oral) antibiotics
Hot compresses
Epilation of the associated lash
412
Molluscum contagiosum
Caused by poxvirus
Present with single or multiple, pale, waxy, umbilicated nodule and shedding of virus may give rise to secondary ipsilateral chronic follicular conjunctivitis
Treatment for lesion near lid margin either by excision or destruction by
cauterization, cryotherapy or laser
413
Contact dermatitis
- Inflammatory response that usually follow exposure to medication, cosmetics or metals
- Present with itching and tearing, lid oedema, scaling, angular fissuring, lid tightness, chemosis (conjunctival oedema)
- Treatment by stopping exposure to allergen, cold compress, topical steroid and systemic antihistamine for severe cases.
414
Atopic dermatitis
- Thickening, crusting, vertical fissuring of lid associated with staph. blepharitis and madarosis
- Treatment with emollients and mild topical steroid & Tx of associated infection
415
Basal cell papilloma (Seborrhoeic keratosis) is
Benign tumour of eyelids skin
416
Characteristics of malignant eyelid tumours
- Ulceration
- Irregular borders & Pearly borders
- Telangiectasia (mostly in BCC)
- Loss of eyelid margin architecture
417
Squamous cell papilloma and basal cell papilloma (Seborrhoeic keratosis) distinguished from malignancy by
Preservation of eyelid architecture
418
BCC is most prevalent malignant eyelid tumor constitute … of eyelid malignancy Majority arise from …
BCC is slow growing & locally invasive but never …
90% — Lower lid — Metastasizing
419
Less common account 5% of eyelids malignancy but potentially more aggressive Metastasis to regional lymph nodes, or may exhibit perineural spread
Tumor has predilection for the lower lid & lid margin, it more common in elderly
SCC
420
How to distinguish between SCC and BCC
Clinically SCC may be indistinguishable from BCC but surface vascularization is usually absent, growth is more rapid and hyperkeratosis is often present
421
Mx of malignant eyelid tumours
- Surgical excision
- Radiotherapy
422
Site & Rx of xanthlesma
- Medial aspect of the eyelid
- Surgical excision or destruction by laser
423
How blepharitis classified
Anterior (around lashes) Blepharitis ~> Staphylococcal type and seborrheic type
Posterior blepharitis ~> Meibomian gland dysfunction
424
Signs of blepharitis
- Hard or soft scale, crusting mainly located around the base of lashes
- Mild papillary conjunctivitis and chronic conjunctival hyperemia
- Capping of Meibomian gland orifices with oil globule
- Scaring & notching of lid margin, madarosis , trichiasis and poliosis
- Tear film instability with dry eye and itching
425
Chalazion
- Sterile chronic granulomatous inflammatory lesion (lipogranuloma) of the meibomian glands caused by retained sebaceous secretions
- Presents ad nodule within the tarsal plate, sometimes with associated inflammation (infected chalazion) referred to as an internal hordeolum
- Rx
1/3 resolve spontaneously
Surgery the eyelid with special clump, the cyst incised vertically & its content curated though the tarsal plate
Steroid injection the lesion is preferable for lesions close to lacrimal punctum because of risk of damage
426
Causes of ptosis
Neurogenic ptosis ~> 3rd nerve palsy or Horner syndrome
Myogenic ptosis ~> Myotonic dystrophy or congenital ptosis or MG (fatigue)
Aponeurotic ptosis ~> Degenerative changes in elderly or post-surgery
Mechanical ptosis ~> Lid tumor or lid oedema
427
What’s ptosis
Abnormal low position of the eyelid, normally it covers upper 2mm of cornea
428
Define retraction of upper lid
When upper lid margin at level or above superior limbus
429
Causes of ectropion
Involutional
Cicatricial
Mechanical
Paralyric
430
Causes of entropion
Involutional
Cicatricial
431
Anatomy of levator palpebral superioris
4cm ~> First 2cm are muscle and other 2cm are aponeurosis
تمشي مع superior rectus (ينضربون سوا) ومسؤولة عن رفع الحاجب بنسبة 90%
432
Tear film consists of
Lipid layer ~> From meibomian glands to prevent evaporation
Aqueous layer ~> From lacrimal glands
Mucin layer ~> From conjunctival goblet cells
433
DDx of horner syndrome
Congenital
Trauma
Pancost tumour
434
Painful horner syndrome
Carotid artery aneurysm
435
How to differentiate between causes of ptosis
3rd nerve palsy ~> Hypotropia + Exotropia + Complete ptosis + Mydriasis
Horner syndrome ~> Ptosis + Miosis + Normal eye movement
Aponeurotic ptosis ~> Orthotroia + Normal movement, reflexes and pupil
436
Associations congenital ptosis
○ Superior rectus weakness because of close embryological association with levator muscle
○ Compensatory chin elevation in severe bilateral cases
○ Refractive errors are common and more frequently responsible for amblyopia than the ptosis itself
437
Rx of congenital ptosis
Surgical treatment should be carried out during the preschool years
In severe cases it’s done before that time
438
Indication of surgical repair in orbital wall fracture
a- persistent diplopia in primary position
b- fracture involve half or more of orbital floor with entrapment of content
c- enophthalmos more than 2mm
439
Thinnest wall of orbit is
Medial
440
M/C wall of orbit vulnerable to fracturing
Floor
441
What’s hyphema
Hemorrhage in anterior chamber, source of bleeding is iris or ciliary vessels, primary hyphema is usually innocuous & absorbed spontaneously
Treated by atropine 1% + steroids + tranexamic acid
442
What’s iridodialysis
Dehiscence of iris from its root , it may be asymptomatic or result in glare& diplopia which may necessitate surgical repair
443
What’s ciliary shock
Ciliary body cease temporarily from aqueous secretion causing hypotony
444
In intraocular foreign body, the … contraindicated
MRI
445
Sympathetic ophthalmitis
Bilateral granulomatous panuveitis occurring after penetrating trauma
rarely after surgery
446
Keratoplasty + chemical trauma
Surgery should be delayed 6m
447
Squint measured by …
Prism diopter ~> Each millimetre equals 15 diopters
448
Motor evaluation of squint
A. Measure ocular misalignment include the Hirschberg test (corneal light reflex test) and cover tests
B. Tests to assess ocular motility by H test
449
What’s glaucoma
Optic neuropathy + Visual field defect + High IOP
450
Aqueous humor production decreased by
- Using drugs
- Ciliary body damage (laser, or cryo therapy)
- Ciliary body shutdown by detachment or inflammation (iridocyclitis)
451
What’s cupping
Increase cup-disc ratio which normally symmetric & less than 0.4
452
Visual field defects in glaucoma
Assessed by perimetry,if progression continue may end with tunnel vision & lastly optic atrophy & blindness
453
Who are the steroid responders
Patients with POAG or Myopia
454
Myopia and Hypermetropia relation with glaucoma
Myopia ~> 1ry open angle
Hypermetropia ~> 1ry closed angle
455
Cloudy (hazy) cornea at birth may result from
Birth trauma
Glaucoma
Congenital rubella
Metabolic diseases like plysaccharidosis
456
When we use antimetabolite such as 5-FU or mitomycin in treatment of glaucoma
For glaucoma with less successeful result from convenitional surgery like neovascular glaucoma, traumatic, inflammatory or congenital glaucoma
457
When we see comitant esodeviation and incomitant
Comitant ~> infantile esotropia ,accommodative esotropia ,sensory esotropia
Incomitant ~> paralytic like 6th CN palsy or restrictive as Duane syndrome
458
When we say this is congenital esotropia
الأطفال قبل 6 اشهر ما يكدر يحرك عيونه سوا مثل الكبار لذلك اول شرط انه الطفل عمره اكثر من 6 اشهر ودرجة الحول كبيرة وماكو اي limitation بحركة العين واهم شيء ماكو refractive errors
